My wife once came with me on
a Saturday morning visit to a psychiatric hospital. I was collecting data for
my PhD, and she met me in the car park of a large psychiatric hospital after
I’d conducted my interviews.As I drove
away, she stroked the back of my hand and suggested that I could relax my
knuckle-whitening grip on the steering wheel. I really didn’t like leaving the
residents behind. I wanted to rescue them.

In mental health, resolving the
relative contributions of our biology and genetics and how these interact with
social and environmental factors (our parenting, peer-relationships, learning, and
experiences of both abuse and nurturing) is more than an intellectual puzzle. I’m
occasionally annoyed by what appears to be a rather simplistic suggestion that,
if there’s a biological, even heritable, element, to a psychological
phenomenon, then we’re inevitably discussing an illness, a disease. Of course
there are biological elements to every behaviour, thought emotion, or human
trait, since they all involve our brains (we don’t, despite the jokes, think
using any other organ and we do, despite the jokes, always use our brain when
we’re thinking). But our attitudes to these issues also have direct personal
implications. As a mental health professional, as a some-time user of mental
health services and (like most of us) as someone with family members with more
serious mental health problems, it’s certainly personal for me.

I’ve spent much of my
professional life studying psychological aspects of mental health problems. Inevitably,
this has also meant discussing the role of biology. I hope I’ve made some
progress in understanding these issues, in working out how the two relate to each other, and the implications for services. That’s my academic day-job. But it’s not just
academic for me. I’m probably not untypical of most people reading this; I can
see clear examples of how my experiences may have affected my own mental
health, but I can also see reasons to suspect biological, heritable, traits. As
in all aspects of human behaviour, both nature and nurture are involved and
they have been intimately entwined in a complex interactive dance throughout my childhood and adult life.

I need to be cautious, because
I don't want to say anything that will irritate my siblings, but I do think
there were oddities in my upbringing. My parents had very strong religious
beliefs, and I think it’s fair to say that, in addition, there was a degree of emotional
repression and our family relationships were somewhat complicated. Just one
example: my parents’ belief system included the need to love God more than
anything or anyone else, including one’s children. So, after my mother’s death,
we discovered that, when she had confessed to a religious mentor that she was
in danger of loving her children more than God, there was a subsequent process
of re-adjustment… she was encouraged to practice loving her children less. My
parents rejected the material world as merely a stepping-stone to heaven (or
hell) and paid little attention to worldly pursuits. I remember opening a
letter from Cambridge University confirming an offer of a place as an
undergraduate. I told my mother, whose reply was; “Very nice dear, now, do you
want baked beans on toast for breakfast?” Pride was a very worldly emotion. I
guess that experiences like that must have had an effect on me and my siblings.

So much for my upbringing. But
like all of us, I was also born with a particular brain. I’ve been educated to
observe signs of neurological as well as psychological functioning (if those
two concepts can be separated). And one of my close relatives has had major
mental health problems throughout his (and therefore my) life. So it’s
intriguing to observe similarities between us and speculate on their origin. Do
we behave similarly because of our shared upbringing, our shared genetic
heritage or (of course) both?

A phenotype

So I am emotionally labile;
my self-esteem and emotions are very fragile and very much dependent on what I
imagine other people are thinking. Or, at least, I think I am; my observations
of my own behaviour are themselves subjective, and it’s possible that others do
these things as much as I do. I frighten myself (given my relative’s
experiences) by fantasising about… winning Nobel prizes, winning Pulitzer
prizes, being elected to this and that, being awarded knighthoods… and that’s
frightening because I’ve seen self-referent fantasies ruin other people’s
lives. My selective attention is terrible and I find it difficult to avoid
distractions. Those who know me well will know that I work with the BBC rolling
news constantly running in the background, and I frequently play games while on
the phone. I appear to have problems with face-recognition; I find it almost
impossible even to recognise the faces of people whom I know well. And when in
conversation with people (in what seems to me to be a potentially related
phenomenon), I find it difficult maintain eye-contact, and look to the side to
line-up images in the distance. And, perhaps most saliently, I lurch forwards
and jump to conclusions in my mental logic. So, if you give me the sequence “A,
B, C” and ask me to complete the sequence, I’ll say Z. Maybe that’s a bit of a
joke (a pun on ‘complete’), and it’s unequivocally good for me in my academic
career. A creative professor is a good professor. I also and simultaneously
make abstract and surreal connections. It’s a recognised part of my teaching
style - I’ll veer off on a tangent. Again, perhaps useful in an academic and
possibly engaging or at least entertaining for students (if they can keep up…).
But jumping to conclusions, tangential connectivity and abstract, ‘clang’ associations all have very interesting connotations
in the field of mental health.

So I am very interested (and,
I hope, open-minded) about what it is, if anything, that we inherit. How do I
differ from other people? What proportion of the variance in these traits can
be accounted for by genetic differences? What proportion of the variance in
these traits comes from being brought up by repressed religious extremists?
What proportion comes from being reinforced, through my childhood, for being
academic? Which elements of my upbringing were different other people’s anyway?

Gene x environment interactions

My tentative conclusions, as
of today, are these: First, my childhood had at least as many oddities and
peculiarities as would capture the attention of any competent psychotherapist.
Second, I believe that my professional eye has identified interesting phenotypes in my close family that reflect potentially heritable
traits. Third, these traits may well put me at risk of many emotional problems.
Incidentally, they may well also make me absolute hell to live with, and I must
give credit to those who have given that a go. Fourth, the interactions of
these heritable and environmental factors in my development have also created a
person – me – that I value and respect. That’s a very odd, solipsistic, thing
to say, but it’s important.

Which leads to my fifth and
most important conclusion. For some people, such as for my relative, these
interactions cause problems. For others, like me, a presumably very similar
pattern of interactions has observable similarities but different outcomes. Of
course we need to consider the contribution of biological as well as
environmental factors in our psychological makeup. I think it’s perfectly
possible to be intelligent and open-minded about the contribution of genetic
and environmental factors in our mental health. We can intelligently and
respectfully discuss how experiences and heritable traits can interact to
produce the wonderful variety of human experience. This, I think, is a much
more accurate and helpful way to conceptualise what’s going on than to say that
some of us – but only some of us - have ‘mental illnesses’. Labels such as
‘schizophrenia’ not only suffer from the validity problems that we’ve discussed
elsewhere [URL], but also obfuscate these important considerations. I don't
think it’s helpful to consider how I have managed to avoid developing
‘schizophrenia’, or whether I have ‘attenuated psychosis syndrome’. To do that,
to reduce these discussions to binary considerations of the presence or absence
of disorders, necessarily constrains the scientific debate. It can also sometimes have frightening
consequences in the real world. When I’ve mentioned some of these issues before
in less public settings, friends and colleagues have often told me that I’m
being brave, and that it’s a potentially risky topic of conversation. So why
might that be?

The eradication of undesirable genetic traits

Part of the reason that people
might be reluctant to talk about such issues is that we have a very poor track
record in this area. This is a difficult topic, but I think it is important to
remember the infamous 1933 Nazi Law for the Prevention of Genetically Diseased Offspring (Gesetz zur Verhütung erbkranken Nachwuchses). Arguments
of genetic science
not only led to the drafting of this law (which permitted the compulsory
sterilisation of any citizens who were judged to possess a ‘genetic disorder’
which could be passed onto their children) but indeed led German-American
psychiatrist Franz Kallmann
to argue that such a policy of sterilisation should be extended to the
relatives of people with mental health problems (in order to eradicate the
genes supposedly responsible). The notorious Action
T4 ‘eradication’ programme was the
logical extension of these policies.

Of course, a focus on
biological aspects of mental health problems is not in any sense necessarily
synonymous with fascism. But for many of us, there are echoes of blame, of
stigma, when we identify the pathology within the genetic substrate of the
person. I’m reminded of Eric Pickles’ notorious throw-away comment to a voter
campaigning about the abuse she’d experienced that she should “adjust her medication”. If
the pathology lies in the person, and particularly if it is a biological
problem, we can dismiss any further troubling considerations.

So one way to understand
these kinds of experiences is to diagnose some form of ‘subclinical’ syndrome,
perhaps attenuated psychosis.
If the
Nazis had won the second world war, I would have been castrated as a
first-degree relative of a ‘schizophrenic’. Disease-model, eugenic, thinking is
a direct threat to me personally, especially given the recent rise of UKIP and
other far-right parties in Europe. I am interested in whether the traits that
make me a good professor may also be related to the traits I listed earlier,
and on their impact on my emotions. I am interested in whether they may have
emerged from a similar mix of genes and environment that led my relative to
experience psychosis. I am very interested in the practical implications; I
have always, for example, avoided certain classes of street drugs. It is absolutely possible to discuss gene ×environment interactions,
but – please – don't use the ‘disease-model’ as a framework.

Acknowledgement: Thanks to Anne Cooke for helpful comments and advice on
earlier drafts.